Pain, Dependence and Universal Precautions:

Working Smarter not Harder in Primary Care

Douglas Gourlay, MD, MSc, FRCPC, FASAM

Wasser Pain Management Centre Toronto, Ontario

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Declaration of Potential Conflict of Interest

• The content of this presentation is non commercial and does not represent any conflict of interest

• I have been compensated for my participation on various Advisory Boards for several Drug Companies

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The Problem

• Pain and Addiction CAN coexist

• Addiction in General Population – Varies 3 – 16% prevalence

– Varies with the drug, gender, economic status, race, age…

• Addiction in the Chronic Pain Population – We really have no idea

– We use the same terms, with different meaning

• Lack of precision in definitions around abuse/dependency/addiction

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Definitions

• Addiction: Addiction is a primary, chronic, neurobiologic disease, with genetic, psychosocial, and environmental factors influencing its development and manifestations. It is characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving. (LCPA)

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Definitions

• Physical Dependence: Physical dependence is a state of adaptation that often includes tolerance and is manifested by a drug class specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist. (LCPA)

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Definitions

• Tolerance: Tolerance is a state of adaptation in which exposure to a drug induces changes that result in a diminution of one or more of the drug's effects over time.

• Tolerance develops at different rates, in different people, to different effects

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Definitions

• Pseudoaddiction: Iatrogenic, maladaptive behavior resulting from inadequate pain control

• Not to be used “instead of” addiction

• Unwise to diagnose in patient with history of addictive disorder, even in other substance

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Addiction *

Biology

Environment

Drug

*

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Pain-Addiction Continuum

Pain Addiction Patient

Patient

Patient

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Diagnosis of Addiction in Chronic Pain

• When the drug is both the problem AND the solution in the patient at the same time i.e. problematic opioid use

– DSM-IV is inadequate

– Addiction is “diagnosis made prospectively, over time”

• Pseudo addiction is “diagnosed retrospectively”

– Careful limits and boundary setting will help to make the diagnosis

The Clinical Approach

• What is the nature of the problem? – Is this a pain problem alone, an addictive disorder or

a bit of both? • If both, which is dominant?

• What is the nature of the pain? – Acute, chronic or acute-on-chronic

• Is the current pharmacotherapy rational? – Is it “doing more to the patient than for the

patient?”

• Do I have the: – Experience to deal with this problem?

– Resources to deal with it?

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Do I have the Resources?

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Integrated models of care create an opportunity to address problems that would be difficult or impossible to otherwise manage

Patient Doctor

Psychiatry

Nursing

Pharmacy

Dietician

Mental Health Counselor

Basic Strategies

• Rationalize pharmacotherapy

– Sometimes better to achieve pharmacologic stability than abstinence

• Short-acting IR agonists can be problematic

– “Agonist debt” can worsen pain

– Higher abuse liability and greater street value?

– Retry previously ineffective agents

• NSAIDs, anticonvulsants, tricyclic antidepressants, etc.

– Consider nonopioid therapeutics i.e. botulinum toxin

– Avoid previous ‘drugs of misuse’

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Basic Strategies

• Set limits carefully, from the outset

– Easier to loosen limits than to tighten them later

– Limits should be flexible and reasonable

• If set too tightly, patient must step outside them

• Assess risk initially and periodically

– Risk is dynamic in pain and addiction continuum

• Appropriate monitoring

– Urine drug testing

– Frequent follow-up

– Interval/contingency dispensing

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Urine Drug Testing

• Effective tool in patient monitoring BUT

– More is not always better

• You CAN monitor high risk patients too often!

• Relying too heavily on UDT can change the focus from therapeutic to “the Gotcha Game”

– There are MANY reasons why quantitative drug testing will NOT answer the questions you think they will

• No reliable relationship between dose prescribed, amount taken and quantity recovered in UDT

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Boundary Setting

• 90%+ of patients don’t need strict boundary setting

– Most patients have their own internal set

• For remaining ~10%, strict boundary setting is essential

• Treatment Agreements, Urine Testing, interval / contingency dispensing

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Boundaries – Identification and Enforcement

Discharge Patient

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Boundaries – identification and enforcement

Consultation with Addiction Medicine

Differential Diagnosis of Aberrant Behavior

• Comorbid psychopathology

– ie, antisocial personality disorder

• Pseudoaddiction

– Behavior driven by inadequate relief of pain

• Active addictive disorder

– With or without a primary pain problem

• Criminal intent

– Drug diversion/trafficking

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Motive vs. Behavior

• “I’m not using the drug to get high, I’m using it to

relieve pain” or “I’m not an addict, I’m a pain patient”

– Separate the ‘motive’ from the ‘behavior’

• “Why” the patient is behaving aberrantly is the motive; the real

question is whether the patient is winning or not with the current

regimen ie, “Is there a problem?”

– Usually easier to get patient and the family to agree that

there is a problem, even if they can’t agree why the

problem exists

– How easily the patient responds to a rational treatment plan

may illuminate the nature of the problem

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“The patient has no legitimate reason to be on opioids”

• It may be true that the original decision to trial opioids was ill advised –

– If the patient has been on opioids for a prolonged period of time, they WILL be physically dependent

• Physical opioid dependence IS a legitimate (and appropriate) reason to be on opioids

– The challenge is how help the patient get from where they are to where they need to be

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Not all aberrant patient behaviour is patient driven

• Running out of pills early, Hording medication, Symptom magnification

– Can all be driven iatrogenically

– Withdrawal, amplified pain etc can result from unreasonable treatment agreements (or their enforcement)

– Treatment Plans must be • Defensible / Rational / Compassionate

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Clinical Pearls

• Don’t do the same thing hoping for a

different outcome

– If patient runs out early “because” you didn’t give

them enough medication, consider increasing the

dose but with tighter limits, ie, weekly dispensing

• If patient is ‘borrowing from tomorrow to pay for today,’

you’ll see this with tighter prescribing intervals

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Clinical Pearls

• Don’t incur an ‘agonist debt’ – If patient is experiencing acute pain, basal opioids

will do little to relieve it. They will need more, beyond what they normally use daily

• The acute setting is not the place to ‘solve’ a substance use disorder

– Identify, Stabilize and Refer

• Don’t miss the ‘golden moment’ when a patient

may see things as they are, not the way they wished they were

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Clinical Pearls

• “You can’t solve a chronic pain problem in the context of an active, untreated addiction”

– Doesn’t mean you can’t treat pain in a patient with substance use disorder

– Unwise to assume that aberrant behavior is due to pain; it can represent a primary substance use disorder

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Clinical Pearls

• “The diagnosis of addiction is made

prospectively, over time”

– What isn’t apparent on the first meeting will become

obvious over time as long as you pay attention to details

• “The diagnosis of pseudoaddiction is

made retrospectively”

– Abnormal behavior that normalizes with rational

treatment supports this diagnosis

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Clinical Pearls

• “It takes 30 seconds to say ‘yes’ and 30

minutes to say ‘no’ to writing a

prescription” ― choose wisely!

– If in doubt, don’t write the prescription

• If you do write, write for a small quantity of drug

• Use “Do Not Fill Until…” to reduce pill load

– Make the prescription contingent on something

• Pill counts; attendance at referrals; UDT samples

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Clinical Pearls

• Be careful interpreting urine drug tests

– Presence of an unprescribed drug may indicate a

problem such as misuse/addiction

• Beware of false positives

– Absence of a prescribed drug may indicate a problem,

ie, bingeing; not using as prescribed

• Beware of false negatives

– UDT is a clinical test for the benefit of the patient

• It should not be used in an adversarial fashion

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Summary

• By consistently applying a basic set of principles to CNCP patients

– Patient care is improved

– Stigma is reduced

– Overall risk is contained

• Universal Precautions is not about opioids –its about good medical care

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Resources

• dgourlay@cogeco.ca

• www.asam.org

• www.udtmonograph.com

– Urine drug testing monograph

• www.cpso.on.ca/Publications/methpain.pdf

– Methadone for Chronic Pain Guidelines